Dementia: using technology to facilitate aging in place, Dr. Frank Knoefel | Ottawa Public Library

♫♫♫ >> All right, so today’s program is dementia, using technology to facilitate aging in place So Dr. Knoefel’s going to talk about the Bruyère Memory Program, which is here in Ottawa, and the potential for smart sensors to identify changes in how people move and think as they get older, to learn patterns and intervene if needed Dr. Frank Knoefel is a physician at the Bruyère Memory Program in Ottawa and senior investigator at the Bruyère Research Institute He holds appointments in the Department of Family Medicine, University of Ottawa, and Systems and Computer Engineering, Carleton University Frank also has extensive administrative experience, including being medical doctor, chief of medical staff, and vice president His research interests are focused on the use of sensors to facilitate aging in place He is cofounder of the Tafetta Program of Research and the AGE-WELL National Innovation Hub, SAM 3 After spending many years working on bed-based sensors to monitor physical wellbeing, such as transfers out of bed and breathing, Frank’s work is now focused more on cognition Sensors in the home can monitor activities of daily living, and soon, artificial intelligence will be able to help cue a person Similarly, cognitive decline can effect driving ability, and the team is studying how technology can help assess and improve driving safely in older drivers Frank is fortunate to be married to Kimberly and have two amazing daughters, Arianna and Corina He enjoys wildlife photography, sailing, and snowboarding And now that I’ve touted all of the amazing things — I didn’t go through all of your credentials You can go ahead and do that if you want to I’m going to pop in here and spotlight Dr. Knoefel and check out myself And Dr. Knoefel, whenever you’re ready, you’re good to go, and then we’ll do the shared screen if you’re ready for that Let me know if you need any help We’ll be here in the background >> Great, thank you very much, Tracey, for that kind introduction, and thank you for inviting me to speak today about two things that I’m very passionate about, care for people with cognitive impairment and technology So, yeah, I’m trying to share my screen, and I have the same problem as I did earlier It says that I am not able to share my screen >> All right, give me a minute We’ll see what I can do to fix that up for you Hang on See if that allows you to do it >> Okay, yes, it looks like we’re through >> Perfect >> And how’s that? Can we see the slides? >> Everything looks great. You’re all set >> Perfect, thank you All right So, here’s the outline for this afternoon’s presentation, so I’m going to begin by talking a little bit about what dementia is, then I’m going to give what I call a technology primer just to talk about how I see technology Then we’ll go into how we can use technology to help with diagnosis and cognitive monitoring Then we’ll look at monitoring activities of daily living using technology Then we’ll explore, can we use technology in cases of more advanced dementia where wandering can be a problem? Finally, I’ll do a quick survey of the kinds of technology that you could buy tomorrow if you were interested in doing that, and finally I’ll wrap it all up So I don’t work by myself I have a huge team that supports the work I do, in particular my partner is Rafik Goubran, who’s vice president of Research and International at Carleton University Bruce Wallace used to be at Nortel, then did a Ph.D. with us and stayed on to help us Heidi Sveistrup is Vice President of research here at Bruyère You see many collaborators, students, people who have helped with administration, and then paid research assistants, as well It takes a village This is an aerial view of Carleton University and the engineering department where our labs are located are there And this is really the birthplace of the technology we’ve worked with We begin with an idea We look at what’s available in the real world, If there’s things we can use, we order them and send them there to Carleton, and the students there take them apart and work with them in the first step

Once we have a working prototype of something, then we bring it to Bruyère, and here this is the Elizabeth Bruyère Campus near the market, where I’m calling from right now, talking from right now And there you see on the fourth floor where we have our smart apartment, our suite where we actually test technology with the older adults And this is what our smart apartment looks like It looks like a pretty ordinary apartment You might notice here on the window sill a couple of smart speakers We do have Google Home. We have Alexa We have a Sonos speaker The television here is actually connected to a computer system so we can remind people to take their blood pressure and to take their weight The bed looks pretty simple, except for the little computer monitor that gives away that there’s actually a pressure-sensitive mat underneath the mattress If you look very carefully, you see little white bubbles hanging underneath the different cupboards These are on/off switches in the kitchen for monitoring use and the light And of course, AGE-WELL has been a big sponsor of our research AGE-WELL is a national Centre of Excellence, and we’ve been working since 2015, and extended now to 2022 for the research Okay, so what is dementia? So being a physician, I always think about this with real people in mind, so this is a fabricated case, but it’s certainly the reality we deal with a lot So we have a 78-year-old lady living alone in a bungalow in Orléans Her daughter lives in Montreal, and she’s noticed some memory problems and also that her mom is having some difficulty managing the finances, so she’s referred to the memory clinic We do some testing, and we find that she has a diagnosis of mild cognitive impairment, but that we feel she’s transitioning to early dementia She wants to absolutely remain living in her home, but of course, her daughter lives far away, and she had — the home care resources are stretched and hard to come by So here this is a real-life problem So let’s just go back and talk a little bit about dementia, so what happens — what we believe happens is that neurons become sick They become sick through various conditions and ultimately die, and what that does, it effects the brain circuits, so just like the cartoon depicts, if we have enough little potholes, if you like, in our brain — in the circuitry in our brain, if there’s enough of them, it’s going to slow down the traffic or the communication in our brain just like the cartoon depicts And if you have enough of that, ultimately, our ability to do things day to day, our functioning, will deteriorate So Dr. Alois Alzheimer in 1906 described the brain of a patient that he was caring for and did this kind of an image and found two particular things that seemed to be unusual in this brain One was amyloid plaques The others were tau tangles, and since that time, we have used still these markers as a sign of memory problems that are associated with the Alzheimer’s type of dementia Even earlier, Arnold Pick had identified inclusion bodies, and they still are included in the diagnosis of what’s called Pick’s Disease, or now we talk about frontal temporal dementia where people have difficulties with language and behavioral issues, in particular, that are the features of that type of dementia Friedrich Louis in 1912 identified Lewy bodies, and Lewy body dementia type, of course, is a type of dementia that involves visual hallucinations and particular features of Parkinsonism with difficulty moving And finally, one of the more common types of dementias associated with vascular damage So if you look here, we have sort of vessels that are feeding different parts of the brain, and you see this

vessel here, we’ve sort of cut it away to show that there’s a clot So that means that there’s no blood flow coming up through this artery here, and this part of the brain is not going to be fed well, so if this brain part was responsible, for instance, for fine movement, then those movements now would not be as healthy as before Obviously, different parts of the brain do different things, and you can see how vascular damage could hurt really any part of brain functioning So, again, brain cells get sick Could it be Alzheimer’s disease? Could it be Pick’s? Could it be Lewy bodies? It could be vascular issues, but ultimately they get sick, the brain circuits are impaired, and the function deteriorates So this slide is one of the more important slides, and it answers the question of, you know, dementia, how does it relate to normal aging and mild cognitive impairment? So here I’m showing that really, normal aging overlaps with mild cognitive impairment, and that overlaps with dementia So aging, we do lose our brain cells after the age of 29 That’s when we have our highest number of brain cells Subsequently, we lose brain cells year over year, and ultimately, it will effect our ability to remember So the memory, it will effect language and executive functioning abilities Aging, though, is usually not associated with changes in our ability to manage instrumental activities of daily living So instrumental activities of daily living would include going to the bank, making a meal, doing shopping in advance of making a meal, and that kind of thing, those higher-order functions of daily living Now, a mild cognitive impairment, there’s enough change in memory or language or executive functioning that an average person can tell and go, Yeah, that seems to be a little worse than just aging And when we test these people, indeed we find that the cognitive abilities are more impaired than normal aging would suggest, however, instrumental activities of daily living are still maintained So let’s say I have a significant memory problem, but I have to pay my bills Now, I know I can no longer rely on just remembering if I paid my bill or not, so now I have to write down on the bill whence I’ve paid it and the date, just so that if later I see that bill again and I can’t remember if I paid, because I’ve written on it, it’s done So a significant change in cognition, but still no change really in instrumental activities of daily living And of course, dementia, then, is changes in memory that spill over into language and executive function or difficulties in language that ultimately spill over into memory and executive function, and of course now instrumental activities of daily living are impaired I forget how to pay bills I forget if I’ve paid bills I forget how to make a complicated meal that requires different parts to start at different times so that the meal is all warm at the right time, and ultimately, I even forget basic activities of daily living I forget to brush my hair, to shave, to shower, to change my clothes, and the like So initially, everyone ages We all will age, but then if there’s more brain cell damage than normal, then we may be pushed over into mild cognitive impairment There are other things other than brain cell damage, however, that can push us into mild cognitive impairment, such as depression If we’re depressed and we don’t feel like doing things, it could look like we have cognitive challenges, but it may impact only the depression So then if we treat the depression, we can actually get back into what would be called normal aging, into that group of people However, it really is damage, then that’s more likely to be irreversible, and over time, that will progress to dementia So we start in aging, we progress over time to mild cognitive impairment, and ultimately a dementia And then we can talk about mild cognitive impairment of

Alzheimer’s type if that’s the change that’s causing us to go from aging to mild cognitive impairment And we can go from mild cognitive impairment to dementia of Lewy body type if that’s the cause of the damage, right? So Alzheimer’s is the cause that we’re moving this way Dementia is this degree of severity of our impairment So we have symptoms, we get eventually diagnosed, we’re monitored As we got monitored over time, the diagnosis may change from mild cognitive impairment to dementia There is functional decline, and we can monitor that And in real life, what’s happening to us is that we may be living at home, then we need services to support us as things deteriorate We may need to move to a retirement home We may ultimately end up in long-term care So the question, of course, today is, what can technology do, either on this side, which is sort of the monitoring, diagnosing and ultimately, you know, what could technology do to delay movement down the line on the right? So now going to move on a little bit to technology So for me, the way I think about technology and aging, first we need some kind of device, a sensor that is going to provide us with information So we can have something as simple as a wall-mounted infrared sensor That would be, like, the kind of sensor you might have had in your home even ten years ago that’s a part of an alarm function, and this can cost as little as $5 for a sensor like that Then you might have a bed pressure sensor This can be as little as $20 but can cost as much as $1,000, depending on how many sensors there are and what kind of activity you want to measure A camera is a sensor, right, because it takes images, and they’re stored, and we can use it for pleasure, but we can also use it for functional measure And finally GPS in a car, we use the map side of things usually, but of course, there is a function of identifying where the GPS is at any given time So the sensors collect data, so a wall mounted infrared sensor simply measures motion Is there motion in the room, or not? And it will simply say, no motion, no motion, no motion, until there is motion And then it will say, motion, motion, until there isn’t anymore And then there’s no motion, no motion So that’s it, simply yes or no is there motion A bed pressure sensor, however, can give a lot of numeric data, so there might be one, there might be 100 points on a pressure sensor like this that provides a pressure value for every fraction of a second So one of the sensors we use has 24 sensors, and they’re sampled ten or twenty times a second, and each of those 24 points, then, gives a number, a pressure Either a low number, meaning there’s very little pressure on it, or a high number suggesting there’s a lot of pressure on that sensor As I said, cameras produce images and GPS ultimately produces a location So now we need to interpret that data, so if it’s a wall-mounted motion sensor, we can say that there’s someone in the room because there’s motion Now, it could be a person. It could be an animal It could be a curtain that’s blowing in the wind But the assumption is if we’ve aimed the sensor right, if it’s at the right height, we can pretty well narrow down that it’s someone in the room If it’s a bed pressure sensor, we could say, Is someone in bed or not, because the pressure, obviously, will be very different if they are But a good pressure sensor with multiple and very sensitive sensors could even detect breathing, so the pressure goes up and down as our chest wall moves and we’re actually breathing A camera could show someone walking and could show someone falling, and a GPS device, as I said, certainly

can give location, but if it says a minute ago you were here, now you’re here, we know how far you’ve traveled, we can measure speed, and we can say, are you moving, are you stopped? So that’s the interpretation of the data that’s been collected Now, finally, a really smart system will be able to produce an action based on the interpretation of the data So a wall-mounted sensor that detects that someone is in the room could turn on the light, and that would be a useful function A bed sensor that identifies that someone has left the bed in the middle of the night that may be at risk of wandering, you might notify the nurse in the long-term care facility, for instance A camera that has detected a fall might notify a family member to check in on their loved one And a fancy GPS device that knows location and that has been pre-set that the vehicle is not supposed to leave the greater Ottawa area, if the car starts moving down Highway 417 towards Montreal, might actually cut off the power in the vehicle to prevent it from leaving the city So you have a sensor, you have data that comes out of the sensor, you interpret that data, and then you might be able to generate an action for a really smart system So let’s talk about diagnosis and cognitive monitoring And so I’m going to show you a graph It looks a little complicated, but it’s actually not that bad So the graph shows function, and it could be cognitive function It could be a memory test that you apply, or something like that, and then it shows over time, measurements of this function, So here we have the results of — we’ll call this the red person, and you can see that day to day there are some fluctuations in the score that this person scores So let’s say this was a mocha test, so they might score 28, 27, 28, 26, 28, 27, 29, 30, right, and that gives you an idea if we were testing every single day what it might look like On the other hand we have this blue person who is the same — we’re measuring the same sort of thing, but over time, you can see there’s a bit of a drift down Now, in reality, I can only see patients once every six months or sometimes once every year, so let’s put on these graphs some random points So let’s say the very first time I see this person at baseline, this is their score, and then I see them a year later and this is their score, and then a year later this is their score So it looks like this person is deteriorating over time, according to these three spots, but of course, if we were to have more data and we were able to do an average, we would be able to determine that this person actually was quite stable over time Now, let’s look at the blue person, and here we have the baseline data, a year later I see this patient again and their score looks pretty much the same as it was before, and then I see them two years later, and again, the score is pretty much the same It looks like this person really has not changed over time, but of course, if we look at their average score, we see that there has been a significant decline for the person Hence, technology would be able to give us more data and hopefully improve our accuracy, so I’m going to give you an example I’m going to give you many examples of research that we have done, but these are just samples, and — just so that you can see how we think about using technology, and now we’re in the domain of diagnosis, right? So here’s a game on the computer It’s called Cognigram, and essentially this part of the test measures speed of processing So as soon as the card turns over and you see the joker, you click on ‘yes,’ and we measure the time delay Then it gets a little bit more complicated

Now the question is, Is the card red? And in this case, of course, it’s a red joker, so we press on ‘yes.’ If it was a black joker, we press on ‘no.’ So now it’s more complicated We can answer how many times did you get it right, and how fast were you at this new additional piece of information And this is real data from patients that have been seen by us here at Bruyère, and we took a group of normal — cognitively normal, older adults, and then we took some people with mild cognitive impairments, so the little circle right beside, right, and we did these tests with them And you can see that consistently, the people with mild cognitive impairment score below the cognitively normal group So theoretically — and this is the work that still needs to be done — a low score on this game — computer-based game, if you like, would be able to help us determine if this is someone who’s cognitively normal or has mild cognitive impairment We also have done research with EEG, and so here you see the cap with the electrodes on it, and so we take all the electrodes, and we get electronic signals coming out of that, because, of course, the brain works through electricity, as I said earlier And then we analyze the data, and sometimes we use NeuroCatch, sometimes we use our own algorithms But here you see one component of brainwaves that we can extract from an ERP, and this is the N100, and you can see in black the normal person, and then you can see in the dotted red line someone with mild cognitive impairment And you can see that the bottom of the curve, which is the point of the N100, happens sooner for the cognitively normal person than the person with mild cognitive impairment So if we go again with our example of potholes on the highway, the person with mild cognitive impairment has more potholes to evade, so it takes them longer to get to the same place than it does for someone who’s cognitively normal So their brain is working because there’s fewer potholes This is slower because of more potholes Now I’m going to talk about another type of game that we designed — that we were involved in designing and testing, and it’s called Whack-a-mole, which many of you know, and this is something we use in people with more advanced dementia, and of course, playing a game produces less stress than being in front of me and me doing cognitive testing Games are advantageous, as well, because education does not seem to impact them as much as tests based on language And of course, people can take this home wherever they live, in rural areas, wherever You don’t have to be in Ottawa to be able to do this, and yet I can monitor your progression So this is a screen very much like a whack-a-mole game Every time a mole pops up, we whack him, touch the screen And in this one, we’ve added a bunny, and the bunnies are our friends, so we don’t whack the bunny So it’s — four times out of five we’ll get a mole popping up, and then randomly, every now and then, we’ll get a bunny that we don’t want to hit So we measure speed of processing and inhibition, and there’s levels in the game, and here we’re taking people that are at a day program — dementia day program, so diagnosed with dementia and cognitively impaired enough that the caregiver needs some respite, right, and we took people, two groups, the people with low MMSE scores, meaning more significant cognitive impairment, and higher MMSE scores And you can see here at baseline, there’s a big difference in the speed with which they play the game, and even over ten weeks, you can see that the groups stay very separate, very distinct But you can see over time that they do get better, surprisingly even the more impaired group over here in the light green improves over time, but just not as much as the less impaired group So we can monitor cognition over time We’re trying to see, can we use technology to help us diagnosis, and we can monitor it over time So what about activities of daily living, because that’s really the most important thing to live

independently, is can we do things by ourselves? So here’s a gizmo that we created in 2012, and you can see it’s wired because in 2012, there was no wireless, right? Now we take wireless for granted, but in those days we didn’t have it So here’s a little switch on the fridge door, and up here we have a box, and the box has a small computer and a big loud speaker, and what we did is, every time you opened the fridge door, after a minute it would say, The fridge door is still open So we sold it to older adults saying, This is just a reminder the door is open If you get distracted and forget to close it, you won’t spoil your milk Of course, behind the scenes, I was more interested in, How often is the fridge door being opened, and to see if I could develop patterns And then if that pattern were to be disrupted, we could say that something is going on in the wellbeing of this person because they’re not hungry, they’re not eating as before So here you see a graph of a real person that we collected data from, and it simply maps the number of times the fridge was opened at various times of the day And not surprising, before 9 o’clock in the morning, there was breakfast Around noon, we had lunch, and then somewhere between 4 and 5: 30, there was supper There was also a little snack in the afternoon and a little snack before bedtime, so this is the pattern we would — sort of a normal trimodal pattern, you know, three meals a day, and if this was, you know, broken on a continuous basis, we would think that would be a marker of change Now, this is the type of research we’re doing now We’ve gone from one sensor to multiple sensors This is in partnership with a group in the U.S And now we have a wearable device that gives us an idea of, What is the person doing? We can weigh them We can monitor their taking of medication with a smart pill box We’re monitoring computer activity, doors opening and closing, and we even have in some cases a sensor in the car that monitors driving And so in driving, we’ve done work looking at distance travel, which is only one dimension, and here what we did is we looked at the health of the driver, and we did both cognitive and physical health, and then we looked at distance from home, and you see that the red drivers, which are less well, spend the large, large majority of their time driving between 0 and 20 kilometres And the healthy drivers have blips at 40, 50, 100, 200 kilometres, which I think is Montreal, and then 400 kilometres, which is Toronto, right, so healthy drivers are more likely to travel far than not so healthy drivers So, again, using a sensor to monitor activities of daily living, and driving is an instrumental activity of daily living, as is making meals, and the like So now we’ve talked about some of the sensing for diagnosing, some of the monitoring of activities of daily living, all of which are really measuring change And they’re helpful to me as a clinician to determine if my treatment is working or if we’ve slowed the change, that kind of thing, but we still haven’t figured out — or we still haven’t shown a smart system So we worked together with the Dementia Society of Ottawa, and we said, If we were able to build a system for you very quickly that included smart sensors and smart technology, what would be the most important thing for you? And they said ‘wandering.’ The thing that most worries us about our partners or family members with — living with dementia is wandering As you can imagine, heading out of the house in the middle of the night in the middle of winter can have tragic consequences for the person with dementia The caregiver, though, especially if it’s a partner and they’re sleeping in the same bed, they worry about this, and every time the bed moves, they wake up, and they are awake until the person with dementia

comes back to bed So of course if you’re not sleeping well, you’re stressed, you’re not as good of a caregiver, and the like So we, working with the Champlain LHIN and other partners, got a set of sensors that we ordered online So now we’re not doing fancy research, the future work, this is real practical So all of these sensors we bought online, so here you have a door sensor, here you have motion sensors, and then here you have a smart plug and a smart bulb This is the hub This connects these sensors to the cloud, to the internet And our research assistant actually went into the home and installed door sensors, put a pressure sensor under the mat, and then used an iPad to program the devices so that they all work together And here’s a smart speaker, the one we use to communicate So what does the system do? So let’s say the person living with dementia wakes up in the middle of the night Usually it’s the bladder calling, so getting out of bed, the light turns on in the hall and leads them to the bathroom And they do their business, and then hopefully they follow the light path back to bed If they go back to bed, the system shuts down, and everything is A-okay Now, let’s say that they get distracted and decide to go to the kitchen Now, there’s a motion sensor there, and it’s connected to the smart speaker, and we use the voice usually of a family member or a partner and we say, you know, for instance, Hello, Peter. It’s still nighttime Please come back to bed So if they listen to that voice and go back to bed, again, the system shuts down and everything goes back to normal, back to sleep However, if they do go on to go to the front door, then of course, it’s a full-on alarm We can have a phone ringing We can have the lights flashing, whatever, and this wakes the person with dementia So first you have the light that guides the person to where they need to go and hopefully back to bed If that doesn’t work we use sound to guide them back to bed and all — throughout all of this, of course, the partner stays fast asleep They don’t need to be disturbed, and only if they go to the front door they’re woken So here’s data from a real person You can see August 31st, and the dark blue line is when they’re in bed So here the person living with dementia goes to bed, and over here they get up And you can see that they were that night three times that they got out of bed And if you look at these sensors that were firing, these are motion sensors, and they always were in the person living with dementia, their bathroom So they had a particular bathroom they went to, and you can see that all three times that night they went to the bathroom and then back to bed shortly after Now, if you take the data, because this study lasted several months in each person’s home, and if you take the data and plot it concentrically with every subsequent day being a new circle, a little bit like the tree, the circle on the tree, you can start seeing patterns So we have midnight here, we have noon here, and then the different times of day and night Now, you can see that the person living with dementia, they’re not completely regular at the times they go to sleep, but typically on average, they sort of go to bed 9:30-ish and they typically wake up 9-ish in the morning They do stay in bed longer sometimes, and they do occasionally get up earlier, but you know, sort of gives you an average, And you can also see that typically — not always, but typically, they’ve been to the bathroom the first time by 1 o’clock in the morning So in a particular case, we — they did get up every single night They went to the bathroom most of the time from 5 to 60 minutes, and they did go to the kitchen once In this case, the partner, the wife had decided she didn’t want to use her own voice She said, Look, he never listened to me when we were married Why would he start listening to me now? So we used Suri’s voice, and the voice said, you know, It’s the middle of the night

Go back to bed Maybe not quite that sternly, but that only happened once, and he said, There was some lady, and she told me to go back to bed I’m never going to go into the kitchen again during the night So there were no falls or injuries, no elopement So that was the good outcome They never, you know, the light guided them The voice guided them, and there were no bad outcomes Now what about the person living with the person with dementia? At the beginning of the trial, she said that she scored — these are standardized rating scales — depression, a moderate depression because worry about, you know, when — is he going to leave in the middle of the night, and that kind of thing After the couple of months of trial, we re-did the score, and she had dropped significantly to a normal wellbeing So the technology monitoring dementia — wandering and dementia, actually, seemed to be working for both people equally well So that’s all I wanted to talk about our research, and I did sort of a quick flyover, but I did want to end with technology that’s currently available and just talk a little bit about the pros and the cons of the different types of technology So you all have probably seen the personal alerts that you can buy, a Philips Lifeline, Red Dot here in Ottawa, a number of companies that monitor these devices And the idea is, if you need help, you press the button, and this calls a call line, and then they call the home and speak through the phone to a speaker system to see if you’re okay or not and if you need help or not This system is very good, however for people with cognitive impairment, they may fall and panic and forgot that they are wearing the device So it’s not always functional in people with cognitive impairment Also, people with cognitive impairment forget what the device is for and are more likely to take them off because it’s irritating them And so personal alerts are very good but they do have caveats in the use Then, of course, there’s all kinds of cool things you can get for your smart phone You can get a reminder — a medication reminder You can get, you know, a calorie counter, and all of these are great tools for staying in shape, for remembering to take medication, but, again, for people with cognitive impairment, they have a little bit less or more limited functionality because they do require you to learn new things And smart phones are quite recent still, so that first you have to learn how to use the smart phone, and then you have to learn how to use the app, and of course, that can be challenging There are, of course, lots of wearable sensors A typical device might measure the number of steps you take in a day It might even remind you to walk every hour or every half hour, depending on the setting It might have a GPS function It typically gives heart rate, maybe blood pressure It might comment on your sleep quality It might be connected to a phone And again, these are useful but may or may not have a lot of meaning for someone with dementia Smart TVs. So TVs are getting smarter Now we can do e-mails, connect to the internet We can watch NETFLIX We can do Skype calls with our TV, and we can do medication reminders that pop up on the TV while we’re watching something else We might have a reminder to take our weight or our blood pressure There are, of course, smart lights These are Philips that I’ve shown They can be fun and give you different colours, different brightness Of course they can be activated by movement, as I talked about in our system We can use sunlight to make a gradual wake up so it gets gradually brighter over time We can link it to music, and that kind of thing There are smart fridges And again, just the smart lights in and of themselves are not necessarily helpful for people with cognitive impairment

Smart fridge, these are still quite expensive You can program in expiration dates You can check if the recipe you’re trying to make, the ingredients are in the fridge You can order food that you need automatically If you’re shopping, you can use the camera feature to actually look inside the fridge and check, Do I still have watermelon? Oh, yeah, there’s some watermelon there and some strawberries So, again, for people with dementia, might with helpful for expiration dates if we’re going to lose our milk, but still pretty complicated I mentioned earlier, smart mattress Cool things like preheating the bed for sleep It can give us sleep report, and some of them can do some kind of staging, as well Again, for people with dementia, themselves may be not helpful, but it could be useful for a family member to know how many times they got up at night or if they left for a couple of hours where they may not have been sleeping There’s communication devices This is a previous version of Alexa You can ask Alexa pretty much anything What’s the time, the date, the temperature today, what’s the news? Can you play my favorite music? You can have a book read through Alexa You can call people, and you can answer questions, and medication reminders are possible using this, as well And again, it does require a certain amount of cognitive ability, because if you just say, What’s the date today, of course, nothing happens You have to start by initiating, Alexa, what’s the date today? And then finally, the first professional-grade system of home monitoring that I’m aware of that’s been put out by industry is Best Buy Assured Living, and this started in B.C And it’s become available, I believe, in Toronto and is coming to Ottawa in the not too distant future, but they actually would install sensors in the home to be able to monitor activities, and you could get a daily report on what’s happened in the last 24 hours So in the future, I see this kind of a world where you see David is trying to get a beer He speaks to his fridge and says, Hal, get me another beer Unfortunately, Hal is not being cooperative and says, you know, because of information on the bathroom scale and the hall mirror, you’re reporting disturbing flab anomalies, and there’s no beer for today So kind of a tongue-in-cheek smart appliance that’s been programmed to take care of health So let’s go back to our lady — 78-year-old lady living by herself in a bungalow, and we’re concerned about her living alone, so what can we do today? Well, as of today, we could get her a set of games that she could play on a regular basis and theoretically, we would be able to extract information about that game playing that would help a clinician, like us here at the memory clinic, to be able to determine over time if she is really transitioning to dementia, or not We can monitor activities of daily living, such as, how frequently are we accessing the fridge, that kind of thing as well Are we taking our medications regularly using a smart pill box, that kind of thing And we can even provide a little bit of assistive functioning, so if she forgets what the activities of the day are, you know, if she remembers to ask Alexa, Alexa can go to her calendar and say, At 9 o’clock, you’re going to have a doctor’s appointment, then — or your daughter’s going to come pick you up and drive you to your doctor’s appointment, and the like And of course communication — various types of communication facilities can be installed So the population is aging Aging in place has always been what older adults prefer Right now with the COVID situation, there’s an increased concern about going into communal living,

so the need for technology to monitor wellness and provide assistance is very, very appropriate It’s very — it’s the time for this kind of technology My team and I have been doing this for a number of years, and the good news is that it’s not only in the realm of research now, it’s really becoming reality that’s being offered by businesses, and the like So that’s all the formal presentation, and I just — another tongue in cheek kind of picture where we have technology and we see the lions have appreciated this flying technology because it provides shade for them So with that, I will end, and I’m happy to answer questions >> Fantastic That was a great presentation Let me check in with my colleague, Stephen He was looking after the Q and A. If anybody happens to have a question that they’d like to add to the Q and A now, please feel free to do that, and we’ll see if Dr. Knoefel can answer those While I’m giving everyone a minute to do that, I have a question for you, actually I’m wondering about the insoles for shoes that have GPS Are you familiar with them? >> Yes >> And do you have any reviews or any information about those? >> Yes. So that is actually a product that’s offered with the Red Dot system here in Ottawa, and I’ve watched the technology over time evolve, and — so it seems like the GPS function on it works, so I have a couple of — I have actually never tested it in the lab Our group, we have never acquired that particular system My reservation is that it is still quite expensive as far as technology goes My other concern is that very few people only wear one pair of shoes, and so if you have five pairs of shoes, are you going to get five sets of sensors, and then not all shoes are compatible, so the idea is very original I think it’s great I think if we can extract information about gait at the same time, so not just, Where is this shoe, but also, How long is the stride, you know, How symmetrical is the gait? If those functions were available, I think it would have additional value But certainly an interesting device, and if someone wants to get me a pair, I’m more than happy to test them out in the lab >> That’s great. That’s great feedback Because I was looking at them actually My father has Alzheimer’s, and it was something I was considering leaving just one pair of shoes near the door that they always use and putting those, and I think that might have worked for him, but it’s great to hear that you’ve got some information about them I’m going to ask my colleague Stephen to open up here with his — are you there Stephen? >> Yeah, I’m here >> Stephen’s going to do the other questions with you >> Yeah, there’s one here: Can you discuss AI or robotics can be used Also, what about virtual reality? >> Okay, those are great questions, and they each require at least an hour to answer properly So let’s talk — let’s start with AI So artificial intelligence is really — if you go back to my sensor picture or where I was doing the primer in technology, the artificial intelligence is really taking the information from the sensors and trying to make sense of them So artificial intelligence would be the — what you use to, for instance, say Where is the person in the middle of the night? The bed sensor says I’ve gotten out of bed, but that doesn’t mean we know where they’ve gone So then you would say, well, there’s a sensor triggered in the hall, there’s a sensor triggered in the bathroom, then no other sensors have been triggered, so the AI would be the designing or the algorithms that decide, well, they’re probably still in the bathroom And if they’re in the bathroom for, like, say an hour, now we start worrying about, Why have they not left, and we might think that they’ve fallen So AI is that ability to use the sensors and to make

deductions and probabilities, and then the AI should activate a function So if someone is after an hour still in the bathroom and not likely sitting on the toilet, not likely showering, then we need to notify the neighbor So the AI would do all that, take the data, analyze it, make probabilistic decisions, and then notify the neighbors. So that’s the AI side Robotics Well, robotics are interesting because they’re devices in the home — so some people call Alexa a robot because you can talk to her, she can answer you But, of course, there are other robots Like, a vacuum cleaner is a robot And then there are robots you can interact with that look more humanoid, like, that have a head and limbs, and there are ones that move around, and so certainly robotics is an interesting technology, as well I don’t have a lot of experience in robotics That’s not what I do I do passive sensing and intelligence based on activities of daily living, but robots can certainly interact with people, they can remind people to take their medications, and so robots are a mobile interaction platform, and the artificial intelligence can be built into the robot, and then certainly they can be connected to the cloud, and they — so it’s a different way of interacting with the person, but, yeah, robotics, there’s a big, big — a lot of research happening there It’s just not my area of expertise And virtual reality, right, so virtual reality is what I would call more of an intervention So let’s say that my set of sensors monitored mobility over time, and we found that the mobility was deteriorating, so I would use virtual reality to design a rehabilitation program, let’s say And I would say that, Well, because of the legs being weaker, let’s do a set of exercises to strengthen the legs, and so I would use virtual reality to create a therapeutic program People use virtual reality, as well, to test ability, so you could do the whack-a-mole game in three dimensions, and certainly, that would be virtual reality for diagnostic purposes, but for me, I think more of virtual reality in the rehabilitation sphere, and — but you can test driving ability with virtual reality. You can do a lot of things You can do — you can test instrumental activities of daily living with virtual reality, as well So virtual reality is another set of technologies that can be used certainly and can be useful, and again, not one that I’m using or terribly familiar with, though Is that good for that set of questions? >> Yes I have — I have another one here The other one was more just perhaps collaborating with you on a project Perhaps we could just pass along my colleague’s e-mail, and we could — it was about a researcher from North Africa who’s working on a project >> Oh, sure >> It wasn’t really within the realm of — >> Yes, if they contact you or you want to forward an e-mail to me, that would be great We’re always looking for collaborators In fact, we’re working with a number of European groups right now, so we’re definitely open to partnerships >> Okay, all right That’s all the questions we have in the chat — in the Q and A area >> So I see something in the chat box on the side Digital apps are tricky Seek some guidance with the Geek Squad at Best Buy stores >> That was my reply, actually >> Oh, that was your reply, okay >> There was someone that was mentioning that the apps are really tricky — >> Right >> — especially for someone that is older and not as accustom to them So I was suggesting maybe seeking some support with something like Geek Squad at Best Buy, and I also mentioned that places like the Ottawa Public Library have tech courses We’re doing some online right now, but of course, then you have to be able to access them using the internet So it is very, very tricky, but do you have any

suggestions on that kind of thing? >> So, yeah, and the observation is very, very good, and of course, the biggest challenge we have is that technology to design it is very complicated, and the trick is to make the technology super user friendly, right, So for instance, in our wandering detection solution, there is no interface, right The people in the home actually do not interact with the technology at all Just by getting off the bed, the light goes on Just by entering a room in the middle of the night, a room you’re not supposed to be in, the technology will speak to you using your partner’s voice saying, Hey, it’s the middle of the night Please go back to bed So, yes, you need the iPad to set it up, but it’s actually part of the service It’s a little bit like the — the Geek Squad will install the Best Buy home monitoring system, and really, you don’t do anything The only — it’s only when you want to interact with the system yourself, so let’s say you want to check your — how many times was I up last night? Then you would have to interact with the system, but a smart — really smart system would be connected to a smart speaker and you could say, Hey, Alexa, how many times did I get up last night, and she’d be able to give you that So I’m not aware of that system existing yet, but certainly interfacing with the technology is a challenge, and really, what we as — our group has focused on is making it completely passive, so that really, you don’t need to learn to do anything You just live your life, and the technology is there to support you >> Excellent That’s great. I think that’s — oh, no, there’s one more that just popped up in the chat Is there any technology that can assist a person with phone messages, someone that is with MCI? >> That’s — that’s great I am not aware of any technology in that way that — I mean, in some ways you could argue that the answering machine itself is already a smart system, right, because you’re not there to answer the phone, and so they leave the message, and it’s there You can play it 100 times, and as long as you don’t erase it, it’s always there to be reverified I mean, obviously, there’s a limit to the number of messages you can keep, so in a way, the technology, the answering machine is already a technology for people with MCI But to take it out of there, how to, then — if you delete the message, how to make sure that something has happened, I’m not sure that’s available Again, it would require some kind of additional step Now, if there was — you know, people with MCI work a lot with sticky note reminders, for instance So if you have a sticky note reminder besides the answering machine that says, As soon as you listen to the message, write down who called and their phone number, and you have a little pad right beside the answering machine and a big yellow sticky note saying, Do not erase before writing the message, you know, that would be the kind of thing you’d do for someone with mild cognitive impairment, because they can still react to some cues, But, yeah, I’m not sure of a technology that’s available, you know, short of recording something somewhere else, but then you’ve already got the recording on the answering machine I’m not sure that would be very — very helpful A smart phone would also still have in its memory bank the last numbers that called, so that’s another way to sort of use that information and cross reference Yeah, it’s a good question, but I’m not sure Right, so, okay, I see someone is saying, that works with the answering machine, but what about if they answer the phone and don’t — and forget to take a message? Yeah, I don’t have a solution for that Again, it’s — for people with MCI, if you could have a notepad right beside the phone with a pen and a big yellow sticky, please write down as soon as someone talks to you, you know, that’s the best we can do If they forget with a pad and a pen and a sticky note

to record the message, then I have to start wondering if we’re not a little bit more impaired than mild cognitive impairment >> There is one more question in the Q and A Is there not a security issue with using Alexa? Does it not record all kinds of information it hears? >> Excellent question So the whole question of privacy is huge, right You know, we collected information about people’s homes, what they were doing at night for several months, 20 people in Ottawa, and all that information went into the cloud, and theoretically, someone could hack into the cloud and take all that information So the — and of course, the level of privacy changes, and so our sensors, the interesting thing was that each sensor had a unique number, a little bit like a car maybe has a unique licence plate or unique VIN number, and all that went to the cloud was a time stamp and yes or no, on or off, right? So these sensors are motion — are motion sensors, so motion or not, but you didn’t even know if it was a motion sensor So all this information went to the cloud Even if someone hacked in, they would not have been able to put together the information to know what was really going on in that home So when we design the technology and when we design the way of analyzing it, of course we have to take into consideration privacy issues If you — you’re absolutely right Alexa is always on, and there’s always information that’s being recorded, and so if you can hack into Alexa, hypothetically, you could hear what people are saying However, trust me, we’ve tried it, it’s extremely difficult to hack into Alexa It’s very, very robust security Now, the people working at Amazon, do they have access to this? They absolutely do, but think about the hundreds of millions of Alexa devices that are recording continuously and then the probability that someone is actually going to want to find one particular message in one particular home, it’s kind of unlikely, but, yes, there are privacy issues, and each company has to deal with them Obviously, video — streaming video online provides a lot more information than individual sensors that are only identified with a numeric code So absolutely, the way you collect data, the way you transmit data, where the data goes, and how you analyze it all requires confidentiality and, of course, researchers that work in our lab, we know which house we put the sensors in No one else does, but we do, so we all sign confidentiality agreements, and all of the students that work, and all the staff that work with us, they know that they can, you know, never divulge this kind of information They work on it for research purposes only But, yes, absolutely, we — we need to think about that Now, on the flip side, there’s Facebook, right, and what people put on Facebook so deifies logic and privacy and personal discretion that, you know, that if I had the choice of having to go to a nursing home or having information from a few sensors in my home going to the cloud, be analyzed, and then connect to my daughter and that gives me a couple more years at home, you know, that might be technology that I would choose, and even pay for, knowing that I’ve exchanged a little bit of privacy for a lot of autonomy in staying at home But it’s a great question >> Yeah, that’s a really great explanation even I think that one of the concerns that keeps coming up in the Q and A in the chat is, How can we possibly expect someone who has cognitive impairment or dementia, how can we expect them to even be able to manage with this technology? And I think what you’re getting at right there even is that it isn’t necessarily the person that has mild cognitive impairment or dementia that is the one that needs to understand all the technology, but rather the technology is in place so that someone, a care partner,

can help to sort of establish what is needed by that person Is that correct? Am I reading that right? >> Absolutely, so you know, the whole purpose of this technology is to provide information and support for the person with dementia, and I’m not saying we — we don’t want the person with dementia to be able to access that, but it will require a big effort on their part, but you’re absolutely right It’s more about the care partners, the family members, care providers, professional care providers, myself as a clinician If I had this continuous game playing data, I would rely on it more than I would my memory test on Tuesday morning at 9 knowing that, you know, that the cognition fluctuates, and I may have gotten the worst or the best part of the day, which is arbitrary and doesn’t give me the real — necessarily their real abilities So absolutely, the — you know, we’re assuming that the daughter that wants to access this information has a smart phone, can log in, and can access information about her mom, you know, how was her day, did she eat today, did she open the fridge, did she turn on the stove And that’s the support we can provide, and if that’s not working anymore, then we get Meals on Wheels, right, and we design the care support for the person with dementia My assumption is not that we’re teaching people that have cognitive impairment a whole bunch of new things. That’s not very realistic >> Amazing Thank you so much for such a great presentation Someone mentioned in the chat that you really make dementia make sense, that you actually speak very well about it and obviously make it make sense That’s years of experience, so it’s just so wonderful that you’re able to share this with us I’m personally very happy that I don’t have a smart fridge in my home right now, because I am working from home, and I would hate for anyone to know how many times I open and close my fridge in a day And I’m glad I don’t have scales, as well Anyways, thank you, again, so much for joining us tonight, and for spending some extra time answering those questions. That’s fabulous I have put my e-mail address to the one person that was interested in collaborating with you so that they could reach out to me and I could pass information over to you I’ve also put the program development e-mail in the chat so it’s If you have any questions or you’d like to connect with us after this, please feel free to e-mail us there Thanks again, Dr. Knoefel That was an amazing presentation We appreciate it so much >> And can I just add that if anyone is interested in participating in research — they have mild cognitive impairment, and they would like to volunteer to be part of research, we are always recruiting Of course, right now our research is on hold because of COVID, but we will be recruiting again shortly on a number of research projects, and of course, we need real people living real lives to test our technology, so if they contact Bruyère, that would be wonderful We’re always looking to recruit >> Fabulous, thanks so much Have a great night everyone. Take good care >> Bye-bye now ♫♫♫